Sample RFP Template

RFP for Oral Disease Prevention Project

Cover Sheet

Applicant Name:Millwood County Board of Education

Contact Information:2114 Weeping LaneSpringwood, WV 25461 321-555-6852

Lead Point of Contact (POC):John Doe

POC Phone Number:321-555-8842

POC E-mail Address:

Grant Title:Oral Disease Prevention Project for Millwood County

Amount Requested:$6,897

Proposed Start Date:March 2016

Duration:2015/2016 Academic Year

Checklist:

Cover Sheet

Agency Description/Capacity

Proposal Narrative

Project Budget/Budget Narrative

Attachments (including MOU)

POC Printed Name:

POC Signature:

Date submitted:
1) Agency Description/Capacity

In one page or less, briefly explain your organization’s qualifications and experience in providing school-based services, history of working with proposed partners, the relationship between your organization and the partners you plan to enlist to carry out this work, current billing capacity, current electronic data entry capacity, and staffing levels for this project. Also explain whether or not your organization has a structure capable of supporting activities, adequate work space, and a facility that is accessible to the disabled community.

Example:

Millwood County Schools (MCS) has been conducting the Healthy Smiles Project (HSP) in partnership with the Midway Health Department (MHD) since 2010. The program targets students ages 6 through 9. The goals of the HSP are to provide prevention services, education and assistance in establishing a dental home. The HSPfocuses on students who have never been to the dentist, or have not been in at least one (1) year. Through this program, local dentists are contracted, along with dental hygienists, to provide oral health services. These services include preventive, restorative and emergency dental care. All findings are entered into a database, and paper records are also kept. The MHD bills Medicaid and private insurances for the services provided through an existing electronic billing system. Staffing includes two (2) dental hygienists, one (1) administrative assistant and one (1) billing clerk from the MHS. All MCS provide private space for students to receive dental services as well as adequate space for storing dental equipment. Allschools in our district have handicapped accessibility.

2) Proposal Narrative

a)Background of the Project

In one page or less, provide background information for the project. Explain the problem that has created the need for the program that this grant will be funding. Include any results from previous projects or evidence that support this request. It is important that the reader who finishes this section knows why your school or district should receive funding for this program.

Example:

The Millwood County School Board has expressed a tremendous need for the ability to have access to oral health care at its school locations due to a high population of transient students (over 46% at one school). Families often move from city to city seeking housing and employment. As a result, many of the students have no medical home for primary or dental care. Throughout the course of the HSP, it has been established that there is an increasing need for funds to be used to supplement current services for uninsured/underinsured students. Funds are also needed to provide sealant materials and supplies, educational materials, and fuel for our van.

b)Program Description/Scope of Work

In three pages or less, describe your plan to implement a school-based dental sealant project in your county, anticipated barriers and how you plan to overcome them, all staffing/volunteer roles and responsibilities, your billing capacity for this project, your capability to enter electronic data into the required database for this project, any priority schools involved with the grant proposal (note: only schools included in the attached list qualify as priority schools), the number of second graders in each school to be served through the ODPP in the 2016-2017 school year, and the number of students in each school (if known).

Example:

In the spring of 2015, MCS and the MHDexpanded the HSP by visiting schools in the district with the goal of educating students about oral health, and providing services as needed in each school with a portable dental clinic. Parent/guardian permission is required for participation in the clinic. Our dental hygienists, Linda Mitchell and Mary Smith, collaborate with school nurses to provide oral health education to students. Students found to be in need of a dental home are then referred to the portable dental clinic. The portable dental clinic is set up at the participating school site, where students receive a thorough screening by a dental hygienist. Services provided at the site are cleaning, fluoride varnish, and dental sealants (when appropriate). Students who participate receive individualized oral hygiene education and supplies to take home.

One anticipated barrier for this project is getting parental consent forms signed and returned in a timely manner. Another barrier is lack of education about the Healthy Smiles Project (HSP) and about the importance of oral health in general. To overcome these barriers, we are taking steps to increase awareness of these matters with posters, an automated call system, and send-home notices. Along with each send-home notice, a consent form will be included in an attempt to overcome the first barrier. If in two (2) weeks a parent still has not returned a signed consent form, that parent will be sent a second consent form with the goal of having it signed and returned. This second consent form will be sent two (2) weeks prior to each clinic. A reminder about the clinic will also be sent two (2) weeks prior to each clinicto parents who have already signed and returned a consent form.

Staffing includes two (2)dental hygienists, one (1) administrative assistant, and one (1) billing clerk from the MHD. The MHD bills Medicaid and private insurances for the services provided at the mobile clinic through an existing electronic billing system. Papers are kept at the MHD, and findings are entered into a database established with the Marshall University School Based Technical Assistance Center. There are five (5) schools involved in this grant: Thompson Elementary (120 students; 22 second graders), Summer Hill Elementary (200 students; 31 second graders), Virginia Elementary (155 students; 27 second graders), Mount Berry Elementary (207 students; 29 second graders), and Griffith Elementary (250 students; 34 second graders). Of thesefive (5) schools, there are three (3) Priority schools. Thompson Elementary, Virginia Elementary, and Griffith Elementary are all on the attached list of priority schools.

Project TimelineTimeline

Construct a table showing the proposed timeline for reaching targeted schools.

Example:

Event / Date
Obtain Public Health Certified Dental Hygiene Certification / March 10, 2016
Distribute oral hygiene supplies to students at assemblies in Millwood County and Walter County / March 14, 2016
Distribute dental enrollment forms/permission slips to all students in Millwood County / April 1, 2016
Distribute dental enrollment forms/permission slips to all students in Walter County / April 2, 2016
Distribute dental enrollment forms/permission slips to all students in Millwood County who have not yet returned them/Reminders / April 15, 2016
Distribute dental enrollment forms/permission slips to all students in Walter County who have not yet returned them/Reminders / April 16, 2016
Conduct Oral Health Workshop and set up/conduct portable dental clinic at Thompson Elementary and Summer Hill Elementary / April 29, 2016
Conduct Oral Health Workshop and set up/conduct portable dental clinic at Virginia Elementary and Mount Berry Elementary / April 30, 2016
Conduct Oral Health Workshop and set up/conduct portable dental clinic at Griffith Elementary / May 3, 2016
Conduct follow-up exams at Thompson Elementary and Summer Hill Elementary / May 29, 2016
Conduct follow-up exams at Virginia Elementary and Mount Berry Elementary / May 30, 2016
Conduct follow-up exams at Griffith Elementary / May31, 2016

c)Assets

  • Briefly describe any assets relative to this project that you already have to fulfill the obligations of this proposal.
  • Briefly describe any assets relative to this project that you need to fill the obligations of this proposal.

Example:

The portable dental clinic currently has the following equipment relative to this project: one (1) portable dental chair, one (1)Nyro G-17 digital X-ray sensor, one (1)Savini I delivery system, one (1)Relco caries detection pen, one (1)Argento air compressor, one (1) laptop computer,and one (1)2013 Ford Transit Van. The portable dental clinic is still in need of sealant material; sealant placement supplies including cotton rolls, saliva ejectors, bibs, prophy brushes and angles, and dental explorers;One (1)Savini II delivery system; promotional material to be distributed to children including toothpaste, toothbrushes, floss, and educational items; fluoride varnish; disposable gowns; and various office supplies listed in budget below.

3) Project Budget/Budget Narrative

Separate budget into individual expenses including all materials, services, etc. with justification for each item and budget total at bottom.

Example:

Budget Item / Cost / Justification
Sealant material / 200.00 / Dental clinic supplies
Cotton rolls / 22.00 / Dental clinic supplies
Saliva ejectors / 35.00 / Dental clinic supplies
Bibs / 28.00 / Dental clinic supplies
Prophy brushes and angles / 340.00 / Dental clinic supplies
Dental explorers / 31.00 / Dental clinic supplies
Savini II delivery system / 4,830.00 / Obtaining a Savini II delivery system will make transportation easier for the dental hygienists. This unit is smaller and lighter than the Savini I, and therefore better suited for a portable clinic.
Toothpaste / 120.00 / Dental clinic supplies/Promotional supplies
Toothbrushes / 244.00 / Dental clinic supplies/Promotional supplies
Floss / 80.00 / Dental clinic supplies/Promotional supplies
Keep Your Smile Healthy! books / 68.00 / Educational supplies
Dental coloring books / 72.00 / Educational supplies
Crayons / 21.00 / Educational supplies
Fluoride varnish / 162.00 / Dental clinic supplies
Disposable gowns / 260.00 / Dental clinic supplies
Binder / 12.00 / Office supplies
Garbage container / 27.00 / Office supplies
Various office supplies (stapler, clip binders, pens, dry erase board, etc.) / 120.00 / Office supplies
Fuel for van / 225.00 / Fuel is needed for the van to travel to the various schools serviced, as well as for transportation of equipment relative to the portable dental clinic.
Total / $6,897.00

4) Attachments

Example:

1. Memorandum of understanding (MOU) for Healthy Smiles Project (HSP)

2. MOU Portable Dental Clinic

3. Millwood County Schools/Midway Health DepartmentStaff Contract

4. Licensure of Midway Health Department dentist

5. Licensure of Midway Health Department dental hygienists

6. Collaborative Agreement for Database Entry Marshall University School-Based Technical Assistance Center

7. Children’s Oral Health in Millwood/WalterCounties data collection form

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